Effective July 1, 2021, UnitedHealthcare resumes our standard credentialing and re-credentialing process and policies. These are consistent with National Council on Quality Assurance (NCQA) standards, as well as any specific state and federal regulations for participation in Medicare and Medicaid programs. Some states may have additional requirements as part of the credentialing and re-credentialing process.
Any temporary changes that were put in place to support practices and facilities from March 19, 2020 through June 30, 2021 will no longer apply. This includes:
Credentialing is required for all licensed individual health care professionals in order to participate in the UnitedHealthcare networks and prior to seeing UnitedHealthcare members. Credentialing assesses qualifications, relevant training, licensure, certification and/or registration to practice. We use this process to help make sure those in our network have the credentials we require to care for our members.
Delegated Credentialing Entities – Update
Effective July 1, 2021, UnitedHealthcare resumes our standard credentialing process and policies, consistent with National Council on Quality Assurance (NCQA) standards. Any temporary changes that were put in place to support practices and facilities from March 19, 2020 through June 30, 2021 will no longer apply. This applies to out-of-network care health care professionals who are licensed independent practitioners and want to participate in one or more of our networks.
Delegated Credentialing Requirements
Credentialing: Provisional credentialing status may be granted for no more than 60 days. Full credentialing must be completed before the end of the 60-day provisional status.
Re-credentialing: Must be completed every 36 months.
Site visits: Requirements for health care practitioners and facilities should be completed or collected, as required, unless federal, state and local restrictions prohibit such visits. Exceptions should be documented in the health care professional’s file.
As of July 1, 2021, UnitedHealthcare’s Delegation Oversight team will complete annual assessments within 12 – 14 months of the prior assessment. All assessments will be performed virtually.
Improvement Action Plans
Improvement Action Plans (IAPs) should be remediated, as scheduled, by the Delegated Credentialing Entity and the UnitedHealthcare Delegation Oversight Team.
If warranted, Delegated Credentialing Entities may implement a provisional credentialing process consistent with the standards set forth by NCQA in order to expedite member’s access to health care professionals. The provisional credentialing process includes:
Receipt of a completed application with a current attestation
Primary source verification of a current, valid license to practice
Review of malpractice history
Evidence of adequate professional liability insurance
Completion of the full credentialing process within 60 calendar days from when provisional credentialing is granted
The benefits and processes described on this website apply pursuant to federal requirements and UnitedHealthcare national policy during the national emergency. Additional benefits or limitations may apply in some states and under some plans during this time.
Medicaid Providers: UnitedHealthcare will reimburse out-of-network providers for COVID-19 testing-related visits and COVID-19 related treatment or services according to the rates outlined in the Medicaid Fee Schedule.
For detailed credentialing updates from UnitedHealthcare, visit here.
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